Research has established the connection between physical environment and the health and safety of the residents in those environments. Institutions in good physical repair that are clean and provide appealing environments are physically healthier for individuals of all ages1. Conversely, environments that are chaotic and in ill repair significantly increase the health risk factors for elderly residents. One of those health risk factors is blood pressure.

Blood pressure is an especially important health measure for the elderly. High blood pressure increases the health risks for stroke and dementia2. Moreover, for individuals with dementia, high blood pressure is especially problematic. Research has shown that elevated systolic blood pressure in particular intensifies the rate of cognitive decline3. There are a number of factors that influence blood pressure. Features in the physical setting such as a waterfall, may be one of those subtle environmental factors influencing blood pressure in the elderly.

Water features have long been used to create stress reducing environments. A number of scientific studies have shown the therapeutic effect of falling water4. The visual and auditory sensations of falling water reduce the physical and mental signs of stress. A number of commercial relaxation tapes incorporate falling water to induce relaxation, reduce blood pressure, and increase one’s sense of well-being.

The present study was set-up as a pilot test. It was designed to see what effect a waterfall infused in the environment would have on the systolic blood pressure of 12 residents with dementia involved in a specialized day care program referred to as the Arizona Room Program.

The Arizona Room Program

Sitrin Health Care Center offers a meaningful program for residents who display disorientation to time and place and/or persons who display behavioral outbursts. This program provides a therapeutic day program with modified interventions to maintain or enhance each resident’s quality of life. The program is called the Arizona Room and includes residents with the diagnosis of dementia or Alzheimer’s. The program promotes physical, cognitive, and emotional health within the context of a small group setting. The Arizona Room has a maximum of 12 skilled nursing residents that participate per day. Residents are recommended for the program by a multidisciplinary team. All of residents personal care needs are performed in the Arizona Room daily. All participants in the Arizona Room are taken to the main dining area for meals and receive the traditional care afforded to all residents in the facility including a plan of care/behavior plan, toileting program, intake/output log, resident daily activity record, social service assessment, interdisciplinary daily progress notes, and attendance logs.

The purpose of the Arizona Room Program is twofold. It offers the resident opportunities for fine motor activities as well as music and culinary stimulation, and it reinforces periods of positive social interaction and lucidity. Information is presented in a repetitive manner to enhance retention and aid in decreasing anxiety.

The study: Waterfall display and healthcare benefits

This Pebble Project is just one of many studies conducted throughout the U.S. designed to demonstrate the effects of physical environment on the health and welfare of individuals receiving healthcare. Pebble Partner Sitrin Health Care Center investigated the healthcare benefits of a waterfall display installed in the Arizona day treatment room. This particular study predicted less stress as evidenced by lower blood pressure for residents exposed to the calming effects of the waterfall display. The study was reviewed and approved by SUNYIT’ Institutional Review Board.

The 12 residents who participate in the Arizona day treatment program for Alzheimer’s at Sitrin’s Arizona Room were included in the study. These residents all have a diagnosis of Alzheimer’s or dementia of some kind. They were chosen for this initial program because of the self-contained nature of the day treatment program which they were already involved in. Informed consent was obtained from the designated health care proxy.

Accents in Water provided a custom water feature for the Sitrin Health Care Center in August of 2005. This water feature consisted of a 304 stainless-steel frame with upper and lower basins covered with a clear tempered glass face. The unit was equipped with both a reverse osmosis water purification and an ozone bacterial controls system. Accents in Water installed the unit and provided training for maintaining and supporting high-quality results from the unit.

Baseline blood pressure readings were taken for each of the residents involved in the Arizona Room four weeks before the installation of the waterfall. Post-installation blood pressure readings were taken for four weeks after the installation of the waterfall by the same healthcare provider. To maintain a level of consistency, the same healthcare provider measured blood pressure for each of the participants in the study. Pre- and post-installation comparisons were made to determine the relative efficacy of the intervention.

Residents were not required to do anything other than what they typically did in the Arizona Room. The staff members already involved in the program remained in the room and carried on with their normal duties during the duration of this study.


A paired-samples t-test was conducted to evaluate the impact of the “waterfall” intervention on the blood pressure of the respective residents. The mean systolic blood pressure prior to the intervention was 127; after the waterfall the mean blood pressure dropped to 123—a decrease of four points. This drop was a statistically significant (t = 2.72, p < .020). Further statistical analysis indicated a small to moderate effect of the waterfall on systolic blood pressure. Nine of the 12 residents registered drops of one or more points in systolic blood pressure after the intervention. For two of the residents, the systolic blood pressure remained the same, and in one case systolic blood pressure went up by two points.

Diastolic blood pressure was also measured pre- and post-installation of the waterfall. In this case, there was an increase in diastolic blood pressure. The mean diastolic blood pressure prior to the intervention was 69; after the intervention, mean diastolic blood pressure was recorded as 71—an increase of two points. The difference was statically significant (t = -2.345, p < .039), but the difference in effect was moderate to low. Of the 12 residents, eight registered an increase in diastolic blood pressure, one remained the same, and three registered a decrease in the readings.


The present study was designed as a pilot. We expected to see changes in systolic blood pressure and the statistical analysis confirmed our hypothesis. However our sample size was small and, therefore, we have to replicate our study to validate these findings. If these findings are replicated, it would suggest that the physical setting and waterfalls in particular might be helpful to elderly residents. Recent research by Shlyakhto5 demonstrated the clinical utility in the elderly of reducing blood pressure for cognitive functioning. In Shlyakhto’s study medication was used to reduce blood pressure, resulting in improved cognitive functioning for residents suffering from hypertension. While the waterfall may not ever replace medication totally, the waterfall display may help to achieve reduced stress and stress-related decreases in systolic blood pressure readings. More research needs to done to ultimately prove the efficacy of the waterfall intervention for reducing systolic blood pressure in the elderly. However, the present results are definitely encouraging for systolic blood pressure.

We did expect to see changes in the diastolic blood pressure readings. We cannot explain why there was an increase in these readings. We would like to see if these findings are again replicated. If we get a replication of an increase in diastolic blood pressure the implications and explanations for the phenomena would need to be explained. HD

Jacqueline D. Warmuth, LNHA, MS, OTR/L, is Director of Clinical Rehabilitation Services at Sitrin Health Care Center. Jacqueline is also an adjunct professor at Utica College. She resides with her husband and two children in New York.

Joanne M. Joseph, PhD, is an Associate Professor of Psychology at SUNYIT. She is currently a co-chair of the Department of Social and Behavioral Science at SUNYIT. Dr. Joseph is the author of a number of professional publications in the field of clinical and social psychology and is the consulting psychologist for Sitrin Health Care Center, and is the recipient of two chancellor’s awards: Teaching and Faculty Service. She resides with her husband in Clinton, New York.


  1. Wentzel C. Measurement of the influence of the physical environment on adverse health outcomes: Technical report from the Canadian study of health and aging. International Psychogeriatrics 2001; 13 (1): 215-21.
  2. Sloog I. The relationship between blood pressure and dementia: A review. Biomedicine and Pharmacotherapy 1997; 51:367-75.
  3. Waldstein S., Carrington R., Thayer J., et al. Pulse pressure and pulse wave velocity are related to cognitive decline in the Baltimore Longitudinal Study of Aging. Hypertension 2007; 51 (1): 99-104.
  4. Jensen BE, Kreitzer MH, Evans EE. The effect of a relaxation program on reducing anxiety prior to oral surgery. In Humphrey J.H. (Ed). Human stress: Current selected research, Vol. 4, 11-28, 1990.
  5. Shylyakhto E. Observational study on cognitive function and systolic blood pressure reduction (OSCAR): Preliminary analysis of 6 month data from > 10000 patients and review of the literature. Current Medical Research and Opinion 2007; 23, suppl. 5:13-18.


The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at


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